Heavy secret

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Noémie La Haye-Caty is a medical student in the Class of 2019 at McGill University

Katy is sleeping on the exam table. She came in looking tired, talking with a weak voice, and walking with small steps. I tried to ask a few questions, but her lack of sleep was evidently preventing her from answering.

She is here today for a follow-up appointment. She was admitted two weeks ago because she wanted to end her life.

I try to gently wake her up. “How are you doing, Katy?”

“Better.”

“Great! What’s better?”

“I was confused, before.”

“Why were you confused?”

Katy is 24 years old and has three young children. She is now a few weeks pregnant. Two of her children were recently taken by the Director of Youth Protection (DYP), while the youngest lives with Katy and Katy’s own mother. Katy tells me that the father of her kids used to be violent with her and has been in prison for the past week.

I can smell the alcohol on her and suspect it may be the reason she is so tired, so I ask her about her use. She acknowledges having binging episodes during which she drinks approximately ten beers at a time, multiple times per week.

“Is there a reason why you like to drink?” I ask.

“What else can I do?” she responds.

I echo her question in my head; what can she do?

Katy has tried to stop in the past. It was always hard because everyone around her was drinking: her boyfriend, her mother, her friends, the rest of the family. She tried harder — Naltrexone, Acamprosate, Disulfiram, you name it. And after that, what do you do? She tells me she doesn’t care anymore; everyone does it, and what’s the point of stopping, anyways?

She doesn’t seem to want to be helped; her sadness is an open wound that does not heal. It is too complex, too unbearable, and too scary to address. I echo the question she asked me earlier in my head; the truth is, the system of injustices she lives in is immense. This encounter reflected something that has failed to be appropriately addressed for decades: the problem of substance abuse in the Québec Inuit population. This issue persists because of the lack of resources offered, and it has disastrous consequences. Ultimately, it perpetuates the discrimination they are already subjected to.

There are fourteen communities in Nunavik with a collective population of 12 090 inhabitants.1 The Régie régionale de la santé et des services sociaux Nunavik conducted thorough research on substance abuse and gambling in this population in 2007 and found that the percentage of the population that drinks daily is slightly lower than that of the rest of the Canadian population.2 What differs is their consuming habits, with 24.2% of the Inuit population binging more than once a week compared to 7.8% for the rest of Canada. A 2015 study looked at the prevalence of alcohol use between 1992 and 2004 in the Inuit population. During that 20-year period, the percentage of young Inuits having heavy binge drinking episodes increased significantly.3

Are things better ten years later? Statistics Canada looked at drinking patterns amongst the Inuits in 2010. Again, the prevalence of alcohol consumption was lower than the rest of the population in Canada, but the rate of heavy drinking was higher. They also note that ‘’use and abuse of alcohol and drugs was ranked by First Nations on-reserve as the top challenge for community wellness.’’4

I can’t imagine what it is like to live in Katy’s situation. I can’t imagine what it is like to grow up in an environment where your cultural identity is marginalized, and where your traditional way of living has been pushed aside to the point that you don’t know if your identity is acceptable in the eyes of others or not. To grow up in a community where the teacher is only there for a few months per year because they can’t find anyone else for the rest of the year. A community where all the authority figures in power are white, where the DYP has an enormous proportion of the children under their supervision, and where suicide rates are alarming.

And then, when all of that is too much and you turn to alcohol — how do you get out of it? How do you get out of it when the only major rehab centre is more than four hours away by plane? You try some medications. And then, eventually, you might go to Portage, one of the major rehab centres in Québec. They don’t speak your language, you are far from home, and it is a cultural shock.

Of course, everything is not black and white. I discussed this with a family physician I worked with when I was in Puvirnituq. She told me that representatives from Portage had started to come to the northern communities to offer follow-up to patients that had been previously admitted to their establishment. This is a good first step toward building a trusting relationship with the population. The only rehab centre in Nunavik itself is called Isuarsivik and is located in the community of Kuujjuaq. This program has existed since 1994 and offers specialized and culturally appropriate substance use disorder treatment to Nunavik’s population. They offer an inpatient treatment program lasting 42 days, which can be completed in Inuktitut. The program offers five cycles per year, welcoming nine patients each cycle.5

But this doesn’t correspond to the scale of the problem; we need more.

I think the underlying reason for this problem is clear: colonialism has had a widespread impact on numerous social determinants of health. We need comprehensive public policies, massive anti-discrimination campaigns, and collective efforts to stop this injustice. We are letting communities which we forced change upon go without health resources, and we must cease this perpetuation of colonialism. Alcohol abuse is a symptom of deeper issues.

I strongly believe physicians have an advocacy role to play in this. The need is astounding, and it should be prioritized no matter the cost.

Two weeks later in my rotation, there is a new admission on the unit. Katy had a fight with her mother at home. She pointed at her own pregnant belly with a knife while intoxicated with alcohol.

Note: The patient in this work is fictitious. Any resemblance to real persons, living or dead, is purely coincidental. However, while “Katy” is fictitious, the case is inspired by true events and could easily represent many real patients.